Occupational Health Referral Form

By submitting this form, you have confirmed the following:
1. That the reason for this referral has been fully explained to the employee
2. That the employee has been informed to expect a text or e-mail from Medmark with a link to data consent information
3. That the employee has been informed to expect a possible phone call from Medmark to obtain further information

Employee Details:
School Case Manager Contact Details:

Please provide details of the School Case Manager who can be contacted to discuss the case if required

If you wish the report to be sent to a different address to above please click here

Referral Type:
Please choose one of the following:


You must attach the Employee's completed and signed CIP Application Form when submitting the CIP Application. If you proceed with this application, the next page will offer you the facility to attach the completed form. The employee must also submit a completed "Treating Consultant Form (Form no. MM180)". It does not need to accompany today's application but should be submitted by the employee or the consultant directly to Medmark as soon as possible. This form can be downloaded at the following link Treating Consultant Form - MM180

Please note that the CIP application cannot be processed prior to Medmark receiving both the above forms